Index

About the Medical Plan

Eligibility and Enrollment

Basic Plan Features

The Prescription Drug Program

Mental Health and Chemical Dependency Care

Covered Expenses

Exclusions

Payments

Claims

Partners in Health

Continuation Coverage

Key Terms

Benefit Summary

Administrative and ERISA Information

Q. What other information do I need to know about the Plan?

A. This section contains technical information about the Plan and identifies its administrator. It also contains a summary of your rights with respect to the Plan and instructions about how you can submit an appeal if your claim for benefits is denied.

The formal name of the Medical Plan is the ExxonMobil Medical Plan.

Plan Sponsor and Participating Affiliates

The ExxonMobil Medical Plan is sponsored by:

Exxon Mobil Corporation
5959 Las Colinas Blvd
Irving, TX 75039-2298

All of Exxon Mobil Corporation's divisions and most of the major U.S. affiliates participate in the ExxonMobil Medical Plan. A complete list of participating affiliates is available from the Administrator-Benefits upon written request. 

Certain employees covered by collective bargaining agreements as well as employees of Station Operators Inc., dba ExxonMobil CORS do not participate in the plan.

Basic Plan Information

Plan Administrator

The Plan Administrator for the ExxonMobil Medical Plan is the Administrator-Benefits. The Administrator-Benefits is the Manager-Global Benefits Design, Exxon Mobil Corporation. You may contact the Administrator-Benefits as follows:

Claims Administrator
The claims administrator provides information about claims payment. The claims administrator is Aetna for medical claims and for mental health and chemical dependency claims and Medco for prescription drug claims.

Claims Fiduciary and Appeals
The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is Aetna for medical mandatory appeals, Magellan Health Services for all mental health and chemical dependency appeals, and the Administrator-Benefits for all prescription drug claims and voluntary appeals. You may contact the claims fiduciary as follows:

Type of Plan
The ExxonMobil Medical Plan is a welfare plan under ERISA providing medical benefits.

Plan Numbers
The ExxonMobil Medical Plan is identified with government agencies under two numbers: the Employer Identification Number, 13-5409005, and the Plan Number (PN), 538.

Plan Year
The plan year is the calendar year.

Plan Funding
Benefits are funded through employee and employer contributions. Beginning January 1, 2014, benefits for certain retirees and their dependents may be funded from an I.R.C. Section 401(h) account established within the ExxonMobil Pension Plan and Trust.

Benefit Claims Procedures

Filing a Claim
A claim must be filed in writing to the appropriate claims administrator:

• Aetna Member Services for medical, mental health and chemical dependency claims; or,
• Medco for non-network and coordination of benefit prescription drug claims.

The claims administrator is responsible for providing you an explanation of benefits and informing you of your entitlement to a benefit and any amount payable to you.

The following categories of claims for benefits apply to the Medical Plan, and according to the type of claim submitted, your claim will be reviewed and responded to within a designated response time. If additional time (an extension) is needed to decide on your claim because of special circumstances, you will be notified within the claim response period.

If you have a problem with a POS II option benefit, contact Aetna Member Services.

Urgent care claims are claims for medical care or treatment that if normal pre-certification standards were applied would seriously jeopardize the life or health of the patient or the ability of the patient to regain maximum function. Also, if in the opinion of a physician with knowledge of the patient's medical conditions the patient would be subjected to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim, then a decision would be made according to the urgent care claim response time.

Pre-service claims are any claims for benefits where the Plan provisions require approval before medical care is obtained (e.g., mental health claims, hospital stays).

Post-service claims are claims for benefits where the Plan provisions do not require approval before medical care is obtained. These claims are made after care is received and apply to claims under the Medical Plan. Most claims are post-service claims.

Denied Claims
If your claim for benefits is denied completely or partially, you, your beneficiary, or designated representative will receive written notice of the decision. The notice will describe:

• The specific reason(s) for the denial.
• Any additional information or material necessary to perfect the claim and an explanation of why such information or material is necessary.
• The process for requesting an appeal.

You should be aware that the claims administrators have the right to request repayment if they overpay a claim for any reason.

Filing a Mandatory Appeal
If your claim is denied, you, your beneficiary, or your designated representative may appeal the decision to the appropriate claims fiduciary. Your written appeal should include the reasons why you believe the benefit should be paid and information that supports, or is relevant to, your claim (written comments, documents, records, etc). Your written appeal may also include a request for reasonable access to, and copies of, all documents, records and other information relevant to your claim. In the case of an urgent care claim, you may request an expedited appeal orally or in writing. You must submit your written appeal within 180 days from the date of the denial notice.

The review will take into account all comments, documents, records and other information submitted relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. You will receive a response to the appeal within a designated response time as follows:

If additional time is needed to decide on your claim because of special circumstances, you will be notified within the claim response period. However, an extension may be requested, but the law stipulates that no additional time will be allowed.

If your appeal is denied, you will receive written notice of the decision. The notice will set forth:

• The specific reason(s) for the denial and the Plan provisions upon which the denial is based.
• A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the claim.
• A statement of the voluntary appeal procedure and your right to obtain information about such procedure or a description of the voluntary appeal procedure.
• A statement of your right to bring an action under section 502(a) of the Employee Retirement Income Security Act (ERISA).

Statute of Limitations
After you have received the response to the mandatory appeal, you may bring an action under section 502(a) of ERISA. Such action must be filed within one year of the date on which your mandatory appeal was decided.

Filing a Voluntary Appeal (not applicable to Mental Health claims)
If your mandatory appeal is denied, you may submit a voluntary appeal to the Administrator-Benefits. New information pertinent to the claim is required for the voluntary appeal to be considered. You must submit your voluntary appeal within 30 days of the denial of your mandatory appeal. The statute of limitations or other defense based on timeliness is suspended during the time that a voluntary appeal is pending.

You will be notified within 15 days after your request was received whether the information was considered new information. If it is determined that there is no new information pertinent to your claim, you will be notified that your voluntary appeal will not be considered. If it is determined that there is new relevant information, a decision will be made within 60 days of the date the Administrator-Benefits receives your request for a voluntary appeal. Note: HMO participants should abide by the claims and appeals procedures stipulated by the HMO.

No Implied Promises

Nothing in this SPD says or implies that participation in the Medical Plan is a guarantee of continued employment with the company.

Future of the Medical Plan

ExxonMobil has the right to change, suspend, withdraw, amend, modify or terminate the Plan or any of its provisions at any time and for any reason. A change also may be made to required contributions and future eligibility for coverage, and may apply to those who retired in the past, as well as those who retire in the future. If any material changes are made in the future, you will be notified. For health plans, certain rules apply regarding what happens when a plan is changed, terminated or merged.

Expenses incurred before the effective date of a plan change or termination will not be affected. Expenses incurred after a plan is terminated won't be covered. If a plan can not pay all of the incurred claims and plan expenses as of the date the plan is changed or terminated, ExxonMobil will make sufficient contributions to the plan to make up the difference. If all claims and expenses are paid and there is still money in ExxonMobil's book reserve established for the purpose of making contributions toward the cost of employees' health care coverage, ExxonMobil will determine what to do with the excess amount in view of the purposes of the plans.

Your Rights under ERISA

As a participant in the ExxonMobil Medical Plan, you have certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that as a plan participant, you shall be entitled to:

Receive Information about Your Plan and Benefits

• Examine, without charge, at the office of the Administrator-Benefits and at other specified locations, such as worksites and union halls, all documents governing the Medical Plan, including collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Medical Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
• Obtain, upon written request to the Administrator-Benefits, copies of documents governing the operation of the Medical Plan, including collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may require a reasonable charge for the copies.
• Receive a summary of the Medical Plan's annual financial report. The Administrator-Benefits is required by law to furnish each participant with a copy of this summary annual report.

Prudent Actions by Medical Plan Fiduciaries
In addition to creating rights for Medical Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Medical Plan, called "fiduciaries" of the Medical Plan, have a duty to do so prudently and in the interest of you and other Medical Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a plan benefit or exercising your rights under ERISA.

Enforce Your Rights

• If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
• Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Medical Plan documents or the latest summary annual report from the Medical Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Administrator-Benefits to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.
• If you have a claim and an appeal for benefits, which are denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the Medical Plan's decision or lack thereof concerning the qualified status of a domestic relations order, you may file suit in Federal court. Any such lawsuits must be brought within one year of the date on which an appeal was denied. If it should happen that Medical Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

Assistance with Your Questions
If you have any questions about the Medical Plan, you should contact Aetna Member Services via the telephone number on your ID card, or call Benefits Administration. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Administrator-Benefits, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

Federal Notices

Women's Health and Cancer Rights Act of 1998
If you have a mastectomy, at any time, and decide to have breast reconstruction, based on consultation with your attending physician, the following benefits will be subject to the same percentage co-payment and deductibles which apply to other plan benefits:

• Reconstruction of the breast on which the mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance;
• Prostheses; and
• Services for physical complications in all stages of mastectomy, including lymphedema.

The above benefits will be provided subject to the same deductibles, copayments and limits applicable to other covered services.

If you have any questions about your benefits please contact Aetna Member Services.

Coverage For Maternity Hospital Stay
Under federal law, the Plan may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section, or require that a provider obtain authorization from the Plan for prescribing a length of stay not in excess of the above periods. The law generally does not prohibit an attending provider of the mother or newborn, in consultation with the mother, from discharging the mother or newborn earlier than 48 or 96 hours, as applicable.